Post on 16-Oct-2020
Marc Geissberger D.D.S., M.A., B.S., C.P.T.,F.N.S.Adjunct Clinical Professor
Department of Preventive andRestorative Dentistry
Marindentist
Marc Geissberger DDS
Treatment Planning, Designing and Delivering Complex and Multidisciplinary Cases
Delaware State Dental Society 2018 Continuing Education Series
March 23, 2018
Monday, March 19, 18
About Me:
Educator - Teach at UOP since graduation in 1991 - Full-Time Until 2018, Adjunct Clinical Professor beginning February 2018Private Practice - Marin County, Ca. since 1991 with Father and Brother.
Product Evaluator - Working with industry to test new products, materials, technologies and deliveries.Speaker / KOL - Member of “CATAPULT EDUCATION” speakers bureau.Family...
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Thanks and Disclosures
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Catapult Group is an organization which consists of top clinicians and educators from throughout the United States and Canada. This group of like-minded yet diverse dentist’s goal is to bring quality education to the dental community via multiple venues including; live lecture, participation, web based, and written formats.
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DISCLAIMER
• As a Catapult Group member we participate in multiple product reviews each year in order to stay at the fore front of the latest materials, techniques and services available, ensuring that the message we are delivering is current and relevant to today’s continuing education needs.
• Some of these products & services we will be sharing with you today.
• Today we are supported in part by:• Voco Clinician’s Choice• Doxa Weave• AMD Orascoptic• Microcopy GC•
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The Catapult/Personal Client Base
AG Nuevo
Air Techniques
Anutra-Medical
Bisco
Denmat
Dentsply
Dentist Select
DMG
Doxa
GC Amercia
Financially Fit
Heraus Kulzer
KavoKerrGroup
Kettenbach
Lending Tree
Microcopy
Perio-Protect
Premier
Proctor and Gamble
Pulp Dent
SDI
Shofu
Solution Reach
Springstone Financial
SS White
Sybron
Triodent
VOCO
Weave
Milestone Scientific
AMD Lasers
Garrison 3M
Ultradent
AdDent
Orascoptic
Clinician’s Choice
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OverridingPrinciples
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Considerations
Macro Issues1) Teeth in proportion to face2) Teeth in proportion to lips3) Teeth in relationship to tissue (gingiva)Micro Issues1) Teeth in relationship to tissue 2) Teeth in relationship to each other3) General proportion of teeth
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Symmetry?Golden Percentage?
* Synonymous with unity
* Subtle diversity is needed because excessive regularity it monotonous
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As Dentists We Focus on Teeth
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Tree and Forest
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Most Important Lesson to Learn in Focusing on The Frame of
Reference(s)
Face Lips Gingiva
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New Technique - Kois Analyser
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Frame of Reference
1) Face2) Lips3) Gingiva
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Range of Lips is Huge
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Lip RepositioningSurgery
1) Becoming a more common procedurelinked to esthetic enhancement
2) Not completely predictable
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Research on SymmetryZaidel D, Aarde S, Baig K, Appearance of Symmetry, Beauty, and Health in Human Faces. Brain and Cognition, 57 (2005) 261-263
Pallett P, Link S, Lee K, New Golden Ratios for Facial Beauty. Vision Research , Nov. 2009,1878-5646
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Symmetry
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Frame of Reference Lip Line
Average Tooth Display 1.91mm Males 3.40mm Females 3.65mm Short Upper Lip 0.59mm Long Upper Lip 3.37mm Under 29 Years 1.26mm 30 to 50 years
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Frame of ReferencePhonetic References
F and V sounds
S sound
incisal display atrest
lingual tilt of themaxillary central
incisors
vertical dimensionof speech
M sounds
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Frame of ReferenceAxial Alignment
22mm Rule
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Snow (1999) suggests Golden Percentages
Idealism and Proportion Golden Percentages
10 15 25 25 15 10
50
30
20
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Frame of Reference Vertical/Horizontal Reference
Lines
1) Midline of the face2) Philtrum 3) Bridge of the nose
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Symmetry and Natural Variation
Dental Midline: Coincided with facial midline in 70% of the population
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Kokich , V. Klyak, A. Shapiro, P.
Comparing the Perception of Dentists and Lay People to Altered Dental Esthetics.
(J Esthet Dent. 11:311-324, 1999) Monday, March 19, 18
Our PatientClinical Condition: I don’t like the space between my front teeth. Patient refuses orthodontic treatment.
Treatment Plan: ?
Rationale: ?
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Chief Concern: I don’t like the space between my front teeth. Patient refuses orthodontic treatment.
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What would you do?
1) Refer her to an orthodontist anyway2) Diastema closure with composite resin or veneers3) Consultation with laboratory to evaluate the possibilities 4) Refer her to another practitioner5) Other
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Spacing Issues
1) Determine etiology2) Plan how to distribute space without the sacrifice of width to length proportion of individual teeth
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Spacing Issues
3) Don’t create wide, short teeth unnecessarily
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Diode (Soft Tissue) Laser
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A"so%"&ssue"laser"incision"at"1000x"
Laser&cut
Superficial"coagula&on
Heat"dissipa&on"with"li;le/no"edema
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!Features
• Number"#1"dental"laser"in"the"world
• More"power"–"3"wa;s• New"easy"to"use"presets• New"treatment"&mers"for"
perio"treatment• Wireless"foot"control• Op&onal"ba;ery"pack• Perfect"for"first"&mers"or"
hygienists• Affordable• Disposable"&ps"or"fibers• Cer&fica&on"included• MSRP:"$4,495• CE"Price:"$3,495
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Ceramics
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All-Ceramic SystemsGlass Ceramics Alumina-based Zirconia-basedResin-based (new)
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All-Ceramic SystemsGlass Ceramics Lithium-disilicate
IPS e.max Press (Ivoclar Vivadent) IPS e.max CAD (Ivoclar Vivadent) IPS Empress 2 (Ivoclar Vivadent)
Leucite IPS Empress (Ivoclar Vivadent) IPS ProCAD (Ivoclar Vivadent)
Feldspathic VITABLOCS Mark II (VITA Zahnfabrik) VITA TriLuxe Bloc (VITA Zahnfabrik) VITABLOCS Esthetic (VITA Zahnfabrik)
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All-Ceramic SystemsAlumina-based
Aluminium-oxide In-Ceram Alumina (VITA Zahnfabrik) In-Ceram Spinell (VITA Zahnfabrik) Procera (Nobel Biocare)
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All-Ceramic Systems
Zirconia-based
Yttrium tetragonal zirconia polycrystals (ZrO2 stabilized by Y2O3) Lava (3M ESPE) Cercon (Dentsply - -Ceramco ) DC-Zirkon (DCS Dental ) Denzir (Decim) Procera (Nobel Biocare)
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All-Ceramic SystemsResin-basedADA’s Council on Dental Benefit Programs Broadens the Definition of Porcelain/ceramics in the CDT Code
(June 13, 2012) The American Dental Association (ADA) will broaden its definition of porcelain/ceramic materials in its CDT Code classification of materials. This classification is solely to aid selection of the appropriate procedure code to achieve uniformity,consistency and specificity in accurately reporting dental treatment. This change also affects insurance claims submission, allowing 3M™ ESPE™ Lava™ Ultimate Restorative to be classified as a porcelain/ceramic. 80 percent nanoceramic particles embedded in a highly-cured resin matrix.
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The Evolution of Indirect MaterialsCast Metal Feldspathic Porcelains Fused to Metal Aluminous PorcelainsThermoplastic Aluminous Porcelain Cerestore
Cast Microcrystaline GlassLeucite Crystalized FeldspathicSlip Cast Alumina with Glass InfiltrationHeat Pressed Lucite Ceramic Glass
DicorFortuneIn Ceram, Procera IPS Empress, OPC
Lithium Disilicate/Fluorapatite Glass Ceramic with dilithium oxide crystals IPS Eris
Milled (Machined) Alumina Based Crowns
Milled (Machined) Zirconium Based Crowns - Stacked
Procera
Cercon, Lava...............
Conventional Jacket Crowns, Viradur
Slip Cast Spinel In Ceram SpinelSlip Cast Zirconia In Ceram ZirconiaHeat Pressed Lithium Disilicate Empress II,
Glazed Magnesia Core Magcor
Milled (Machined) Leucite Based Crowns Pro-Cad
Emax
Milled (Machined) Zirconium Based Crowns - Monolithic Cercon, Lava...............
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Flexural StrengthFlexural strength, also known as modulus of rupture, or bend strength, or transverse rupture strength is a material property, defined as the stress in a material just before it yields in a flexure test. The transverse bending test is most frequently employed, in which a specimen having either a circular or rectangular cross-section is bent until fracture or yielding using a three point flexural test technique. The flexural strength represents the highest stress experienced within the
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Fracture Toughness
Fracture toughness is a property which describes the ability of a material containing fracture, and is one of the most important properties of any material for many design applications. The linear-elastic fracture toughness of a material is determined from the stress intensity factor (K) at which a thin crack in the material begins to grow.
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Zhenzhen Zhang, Yuanping Yi , Xuesong Wang, Jiawen Guo, Ding Li, Lin He, Shaofeng Zhang A comparative study of progressive wear of four dental monolithic, veneered glass-ceramics. Journal of the Mechanical Behavior of Biomedical Materials, Volume 74, October 2017, Pages 111-117
lithium disilicate glass-ceramic
leucite reinforced glass-ceramic
feldspathic glass-ceramic
fluorapatite glass-ceramic
FractureToughnessHigh to Low
FlexuralStrength
High to Low
Wear of Opposing
High to Low
1 1 4
2 2 3
3 3 2
4 4 1
Wear of Various Dental Ceramics
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Wear of Various Dental Ceramics
lithium disilicate glass-ceramic (Adjusted)
Wear Rate on Enamel
Low to High4
2
3
5
Nathaniel C. Lawson , Sridhar Janyavula , Sarah Syklawer , Edward A. McLaren , John O. Burgess. Wear of enamel opposing zirconia and lithium disilicate after adjustment, polishing and glazing. journal of dentistry 42 (2014) 1586–1591
lithium disilicate glass-ceramic (Adjusted/Polished)
lithium disilicate glass-ceramic (Adjusted/Glazed)
zirconia (Adjusted)
zirconia (Adjusted/Polished)
zirconia (Adjusted/Glazed)
RelativeValue in mm3
.53
.36
.47
.54
1 .33
6 .68
Veneering Porcelain (Glass) 7 2.15
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Metal
TitaniumBase
NobleHigh NobleCeramic Metal Ceramic
Composite
Metal Acrylic Base
High Noble
NobleMilledPres
sed
Stacked
Stacked
CastPressed
Milled StackedStain
Cut-Back
Titanium
Base
NobleHigh Noble
Zirconia
Disilicate MilledAlumina Zirconia
Alumina
Disil
icate
Alum
ina-Z
ircon
ia
Al-Zir
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Flexural Strength of Dental Ceramics (MPa)
Aluminous Porcelains
Cast Microcrystaline Glass
Slip Cast Alumina with Glass Infiltration
Heat Pressed Lucite Ceramic Glass
Dicor
In Ceram, Procera
IPS Empress, OPC
Milled (Machined) Alumina Based Crowns
Milled (Machined) Zirconium Based Crowns
Procera
Cercon, Lava
Conventional Jacket Crowns, Viradur
Slip Cast Spinel In Ceram Spinel
Slip Cast Zirconia In Ceram Zirconia
Heat Pressed Lithium Disilicate Empress II, e.max
Glazed Magnesia Core Magcor
Milled (Machined) Leucite Based Crowns Pro-Cad
125
135
140
151
269
350
400
350
650
650
900
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Lava Ultimate
Monolithic Zirconia OpaqueeMax
Longevity vs. Beauty
Long Life
Great Esthetics
Short LifeYears
Poor EstheticsEsthetics
Gold
PFMMilled Zirconia - Stacked
Feldspathic Porcelain
EmpressMonolithic Zirconia Translucent
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Why Have So Many Gone Away?
Answer: They Break
Fractured Dicor Crown Fractured Inceram Crown
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What About Porcelain Fused to Metal?
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Types of Ceramic-Metal FailurePorcelain Porcelain Porcelain
MetalMetal Oxide
Metal MetalMetal Oxide
Porcelain
PorcelainMetal Oxide
Metal
Porcelain
Metal OxideMetal
Metal OxidePorcelain
Metal Oxide
Metal
Metal
Type I: Metal-porcelain Type II: Metal oxide-porcelain Type III: Cohesive within porcelain
Type IV: Metal-metal oxide Type V: Metal oxide-metal oxide Type VI: Cohesive within metal
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Porcelain IssuesDhima M, Paulosova V, Carr AB, Rieck KL, Lohse C, Salinas T, J J Prosthet Dent. 2014 Feb.
Practice-based clinical evaluation of ceramic single crowns after at least five years.Survival Rate: 95% (5 year) 92% (10 year)# 1 reason for failure: Fracture to core of layered restorations
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Porcelain IssuesRinke S, Schäfer S, Lange K, Gersdorff N, Roediger M., J Oral Rehabil. 2013 Mar.
Practice-based clinical evaluation of metal-ceramic and zirconia molar crowns: 3-year results.
Survival Rate: PFM 97.6% Zirconia 95.2% Success Rate: PFM 90.9% Zirconia 86.6%
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Pieger S, Salman, A, Bidra A, Journal of Prosthetic Dentistry. 2014 July.
Clinical Outcomes of Lithium Disilicate Single Crowns and Partial Fixed Dental Prostheses: A Systematic Review
Single Crowns Fixed Dental Prostheses 2 Year Survival Rate: 100% 83.3% 5 Year Survival Rate: 97.8% 78.1%10 Year Survival Rate: 96.7% 70.9%
Porcelain Issues
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What Haircut is this?
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The Oral Cavity
The Mullet “Business in the front,partying in the back!”
The Reverse Mullet
“Party in the front,business in the back!”
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Your Choices Today
Bilayer BranchMonolithic Branch
Zirconia
Disilicate
Metal
DisilicateZirconia
Metal
Pressed
CompositePressed
Milled
PressedStacked
Stacked
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Production ComparisonSingle Unit Crowns - Gold vs. PFM vs. Ceramic
11 -12 Numbers
12 -13 Numbers
11 -12 Dollars
12 -13 Dollars
13 -14 Numbers
13 -14 Dollars
Gold PFM
709 1320
% %
30.7 57.3
$445,774 $841,67929.4 55.6
631 133926.0 55.2
$402,465 $889,44724.1 53.3571 100923.6 41.7
$378,390 $681,40022.8 41.1
Ceramic
276
%
12
$225,091 15
457 18.8
$378,161 22.6
835 34.7
$596,981 36.1
14 -15 Numbers
14 -15 Dollars
353 47617.8 24.0
$235,579 $313,23517.8 23.7
1152 58.2
$770,679 58.5Monday, March 19, 18
Statics from Glidewell
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Solid Milled Zirconia
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Solid Milled
Zirconia
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Traditional Examples
1000-1400 MPa
1200 +/- 200 MPa
1100 MPa
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Translucent Examples
750-560 MPa
700 +/- 100 MPa
650 MPa
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3M - Lava Plus and Lava Esthetic
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3M - Lava Plus
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Pressed or Milled Lithium Disilicate
e.max Press e.max CAD
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Benefits of eMax
Good StrengthEtchable - Bondable4 Levels of OpacityMultiple Different TechniquesVery Good Esthetics
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eMax
HT ingotsThe high translucency ingots (HT) are suitable for the fabrication of minimally invasive full-contour restorations, such as inlays, onlays and veneers. The restorations are characterized with staining materials.
LT ingotsFull-contour partial crowns and crowns are fabricated with the low translucency ingots (LT). In the anterior region in particular, the esthetic appearance of the restorations is maximized by employing the cut-back technique.
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eMax
MO ingotsThe medium opacity ingots (MO) are used to fabricate substructures for vital or slightly discolored teeth. They create an ideal basis for lifelike restorations completed with the layering technique.
HO ingotsIn cases where the prepared tooth structure is discolored or titanium abutments are used, the HO ingots mask the dark background to achieve highly esthetic results.
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Clinician’s Choice Polishing
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What Would You Do?
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Is it Perfect?
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MT and Impulse Ingot Added
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Teeth Following Crown Removal
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Reduction Matrix
Fabricated from the Diagnostic Wax-up
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Pressed Material Design Anterior Teeth
1) Round End Taper (1116)2) Esthetic bevel of 1/2 to 1/3 occ-ging height3) Incisal reduction of 1.5 - 2.0 mm4) Lingual reduction of 1.5 to 2.0 mm (1900)5) Well rounded line and point angles (essential)
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Types of Luting Agents1) Zinc Phosphate Cement2) Polycarboxylate Cement3) Glass-Ionomer Luting Cement4) Resin-Modified Glass-Ionomer Cement5) Polyacid-Modified Composite Cement6) Resin-Based Cement7) Bioceramic Luting Agent
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RMGI Luting Cement
Advantages:1) Less sensitivity to moisture during setting2) Capable of bonding to composite
Disadvantages:1) Hydrophilic behavior2) Leakage between water-based cements and resin-based
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Resin Cement
Advantages:1) High values for bond strength2) Highest adhesion
Disadvantages:1) Challenging clean-up2) Potential for post-op sensitivity
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al
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6th Gen. Product Examples
1) Clearfil SE Kuraray 2) Optibond XTR Kerr3) Peak SE Ultradent 4) Prelude Danville5) Adhese SE Ivoclar 6) Prompt-L-pop 3M ESPE7) Adper Scotchbond SE 3M ESPE
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7th Gen. Product Examples
1) Scotchbond Universal 3M2) Optibond All-in-One Kerr3) Futurabond Voco4) Clearfil S3 Bond Kuraray 5) iBond Kulzer6) Bond Force Tokuyama
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Resin Bonding Cements
Ivoclar Variolink IIDentsply Calibra
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Ceramir®
The product combines Ceramir technology and some glass ionomer components to provide the best properties for the material.
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+
PFM, All Metal,or Zirconia on
All Teeth
or
or
Empressor eMax
or
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or+
+
+
+
PFM, All Metal,or Zirconia on
Non-Vital Teeth
or
or
PFM, All Metal,or Zirconia on
Vital Teeth
or
Empressor eMax
+
or+
or
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Magnificationand
Illumination
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Orascoptic
Geissberger, M. J. (1995). The Effects of Magnification on the Performance of Fixed Prosthodontics Procedures. Journal of the California Dental Association, 23(12), 66-70.
Monday, March 19, 18
The World’s First Loupe With A Built-In Headlight
!All electronics are completely contained within the frame. No more cables to get tangled on chairs, doorknobs, or drawers. Built-in side shield protection (separate side shields not necessary). Small ultra-lightweight headlight
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OrascopticSparkLight
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Magnificationand
Illumination
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Orascoptic
Geissberger, M. J. (1995). The Effects of Magnification on the Performance of Fixed Prosthodontics Procedures. Journal of the California Dental Association, 23(12), 66-70.
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Orascoptic - Options
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Orascoptic LED Light
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SimulatedSmile
Design
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Before Simulation After Simulation
Van Zyl, I., Geissberger, M. J. (2001). Simulated Shape Design: Helping Patients Decide Their Esthetic Ideal. Journal of the American Dental Association, 132, 1105-1109.
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Simulated Smile Design
Step One: Diagnostic Impressions
Impressions:* Must capture all tooth anatomy* Must capture entire buccal vestibule* Use Resin Rock (Ivory) or similar product
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Simulated Smile Design
Step Two: Stick Bite
* Use fast setting bite registration * Place first stick on the incisal edge of lower anterior teeth* This must be parallel to the in. pup. line* Second stick is placed at the patient’s midline
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Simulated Smile DesignStick Bite
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New Technique - Kois Analyser
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Simulated Smile Design
Step Three: Mounted Diagnostic Casts
* Can be mounted arbitrarily * Use semi-adjustable articulator
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Simulated Smile Design
Step Four: Diagnostic Wax-up
* Can employ laboratory* Must reproduce all desired anatomy and effects* Most critical portion of entire technique* Is the make or break of the process
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Midline
8.5&mm
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Critical Anatomic Features
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Simulated Smile DesignWax-up
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Simulated Smile Design
Putty Splint Fabrication
* Must capture all wax-up anatomy* Must capture entire buccal vestibule* Should extend two teeth past wax-up on either side
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Simulated Smile Design
Try-in and Midline Mark
* Make sure splint can be positioned easily* Mark the midline as a reference for seating* Ensure occlusal stops are adequate
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Simulated Smile Design
Dry All Surfaces
* Use 2X2 to dry facial of all teeth* Have patient keep these surfaces dry
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Simulated Smile Design
Load Bis-Acrylic
* Place mixing tip on incisal edges* Fill all aspects of the facial surfaces of teeth
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Available Bis-acrylic Resins
Monday, March 19, 18
Available Bis-acrylic Resins
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Simulated Smile Design
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Simulated Smile Design
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Simulated Smile Design
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Step Eleven: Surface Characterization
* Apply composite surface stain * Light cure when desired result accomplished* Polish lingual area with finishing disks
Simulated Smile Design
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Before Simulation After Simulation
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16 Years later
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Psychologyand Patients
Monday, March 19, 18
Roger Sperry
• “Our educational system, as well as science in general, tends to neglect the nonverbal form of intellect. What it comes
down to is that modern society discriminates against the right hemisphere.”
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LEFT BRAIN FUNCTIONS
uses logic
detail orientedfacts rule
words and languagepresent and past
math and sciencecan comprehend
knowingacknowledges
order/pattern perceptionknows object name
reality basedforms strategies
practicalsafe
RIGHT BRAIN FUNCTIONS
uses feeling
"big picture" orientedimagination rules
symbols and imagespresent and future
philosophy & religioncan "get it" (i.e. meaning)
believesappreciates
spatial perceptionknows object function
fantasy basedpresents possibilities
impetuousrisk taking
http://similarminds.com/cgi-bin/brain.plMonday, March 19, 18
What Does the Opposite Sex Look At First?
Female looking at Male Male looking at Female1) Brain
2) Eyes
3) Smile
4) Height
5) Butt
1) Eyes
2) Smile
3) Breasts
4) Butt
5) Legs
Monday, March 19, 18
Most Popular Procedures
Surgical Procedures: 2000 20161) Breast Aug. 212,500 290,4672) Liposuction 354, 015 235,2373) Rhinoplasty 389,115 223,0814) Eyelid Surgery 327,514 209,0225) Facelift 133,856 131,106
Non-Surgical1) Botox 786,991 7,056,2552) Soft Tissue Fillers 658,885 2,600,8683) Chemical Peel 1,149,457 1, 360,8504) Laser Hair Removal 735,996 1,109,3855) Microdermabrasion 868,315 775,014* American Society of Plastic SurgeonsMonday, March 19, 18
Not AllAestheticMindsets Are Alike
Monday, March 19, 18
What Constitutes
An Appealing
Smile?
Which Celebrities have the best smile?
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Best Celebrity Smiles
2006
HALLE BERRYTIGER WOODS
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Best Celebrity Smiles
2008
EVA MENDESBRAD PITT
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Best Celebrity Smiles
2010
JESSICA ALBABRAD PITT
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Best Celebrity Smiles
2012
ANNE HATHAWAYMATT DAMON
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Best Celebrity Smiles
2014
JUILA ROBERTSGEORGE CLOONEY
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Beauty
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Assessing Health Consciousness Kraft F, Goodell P, Identifying the Health Conscious Consumer.
Journal of Health Care Marketing (Fall 1993) 18-25
1) I worry that there are chemicals in my food 1 2 3 4 5
2) I’m concerned about drinking water quality 1 2 3 4 5
3) I try to exercise at least 30 min. a day, 3x a week 1 2 3 4 5
4) I exercise more than I did three years ago 1 2 3 4 5
5) Good health takes active participation on my part 1 2 3 4 5
6) It is my doctor’s job to keep me well 1 2 3 4 5
7) My daily meals are nutritionally balance 1 2 3 4 5Monday, March 19, 18
Assessing Health Consciousness Kraft F, Goodell P, Identifying the Health Conscious Consumer.
Journal of Health Care Marketing (Fall 1993) 18-25
8) I try to avoid high levels of cholesterol in my diet 1 2 3 4 5
9) I attempt to avoid stressful situations 1 2 3 4 5
10) I only worry about my health when I get sick 1 2 3 4 5
11) I spend time each day trying to reduce accumulated stress 1 2 3 4 5
12) I believe that the “wellness” idea is a fad 1 2 3 4 5
13) Exercise helps me succeed in all facets of life 1 2 3 4 5
14) Air pollution does not bother me 1 2 3 4 5
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Tate, Peter, The Doctor’s Communication Handbook, 5th edition
Monday, March 19, 18
Types of Patients
The Internal Controller.This type of person believes that fundamentally they are in charge of their own future health.
There are certain implications for this type of believer, not least that they tend to get very cross if they do get ill.
As far as communication is concerned, this type of person likes explanations, dialogue and Socratic discourse.
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Types of Patients
The External Controller.What will be will be. They are fatalists. There are certain implications for this type of believer, not least that they tend to get very cross if they do get ill.
They are not really much into involvement and take little or no interest in the media obsession with matters of health.
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The Powerful Other.This type of patient is quite different from the others. They do not believe they are in control of their own health nor are they fatalists. They believe the Doctor and the Doctor alone is in charge of their health.
Strategies of trying to give such patients more responsibility for their own health are firmly resisted.
Types of Patients
Tate, Peter, The Doctor’s Communication Handbook, 6th edition
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Our Next PatientClinical Condition: Worn dentition, periodontal disease, “looks like a rabbit”.
Treatment Plan: ? Desires: Wants problem fixed.
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Chief Concern: I look like a rabbit!Monday, March 19, 18
Radiographs
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On a scale of 1-10, how difficult is this case?
1) Simple (1-2)2) Routine (3-4)3) Average (5-6)4) Complex (7-8)5) Wow! Extremely Challenging (9-10)
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Material Selection
1) Choose materials for aesthetics and compatibility
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Material Selection
2) Utilize materials designed to maximize optical appearance when placed next to each other
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Jan 2011 Emergency Visit
Your Front Tooth BrokeMonday, March 19, 18
What Would You Do?
1) New Post and Build-up #9, New Crown #92) Ext. #9, FDP # 8-103) Ext. #9, Implant #94) Ext. #9, RPD to Replace5) Other
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One Year Recall PA Jan. 2012
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Develop Your Own Rating System 1 through 10 ranking
1) Simple (1-2)2) Routine (3-4)3) Average (5-6)4) Complex (7-8)5) Wow! Extremely Challenging (9-10)
Patient Disposition Patient Belief OrientationPatient Treatment GoalsLip PositionMaterials PresentSupporting StabilityGingival Biotype
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Ways of Categorizing Treatment Plans
1) Urgent Care2) Disease Control3) Reconstructive Phase4) Maintenance Phase
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Urgent Care
1) Pain2) Active Infection3) Chief Complaint
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Disease Control
1) Periodontal Disease2) Caries3) Occlusal Disfunction - Diseases of Habit4) Asymptomatic or Endodontic Infection
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Caries Data
ROBERT A. BAGRAMIAN, DDS, MPH, PHD, FRANKLIN GARCIA-GODOY, DDS, MS & ANTHONY R. VOLPE, DDS, MS
The global increase in dental caries. A pending public health crisis
(Am J Dent 2009;22:3-8) Monday, March 19, 18
≤20%21-25.9%
≥35%Data unavailable
Source: BRFSS 1995-2000
26-34.9%
Edentulism, Age 65+ 1995-2002
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Edentulous Rates
Source: World Health Organization 2005 ReportMonday, March 19, 18
How Do We Stack Up World Wide?
Source: World Health Organization, Global Health Data Bank, Geneva: 2011
GambiaEgyptChina Cambodia LithuaniaAustriaIceland Slovenia ThailandIndia Italy LebanonSingapore IndonesiaPoland
Madagascar Romania United States DenmarkHungarySaudi ArabiaSri LankaFinland Slovakia United Kingdom Bulgaria Malaysia Canada Albania Bosnia
6.0 7.0 11.013.0 14.015.015.016.016.319.019.020.0 21.024.025.0
25.0 26.026.027.027.036.037.041.044.046.053.057.058.069.078.0
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Periodontal Disease
1) Mechanical Approach2) Chemotheraputic Approach3) Surgical Approach
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Clinical Findings
#2 large B Caries #12 F caries
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Caries
1) Improve Oral Hygiene 3) Alter the Flora2) Strengthen Enamel 4) Control and Alter PH
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Radiographic Findings
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Restoration of Aproximal Lesions
Modern concepts in disease management must treat the disease, not the signs of disease.
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Modern concepts in disease management must treat the disease, not the signs of disease.
Restoration of Aproximal Lesions
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Ultradent Products
Caries Management: Transitioning from Education and Research to Improve Patient Care, New Directions in Interorganizational Collaboration in Dentistry: The CAMBRA Coalition Model
Douglas A. Young, D.D.S., M.S., M.B.A.; Philip M. Buchanan, D.D.S.; Richard G. Lubman, D.D.S.; Norena Norton Badway, Ph.D.
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Trivia TriviaWhich drink has the
greatest erosive potential?
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Literature on Sports Drinks
Sports drinks and dental erosion.
J Calif Dent Assoc. 2011 Apr;39(4):233-8.
Noble WH, Donovan TE, Geissberger M.
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CariesManagement
Measure/AlterpH
Control/AlterBacteria
Strengthen ToothStructure Enhance Salivary
Function
Patient Issues
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Control/AlterpH
Strengthen ToothStructure
Control/AlterBacteria
Enhance SalivaryFunction
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Measure/AlterpH
Strengthen ToothStructure
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Strengthen Tooth Structure1) Clinpro Tooth Creme (3M)2) Mi Paste (Plus) (GC)3) Fluoride Varnish Profluorid (Voco)
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3 Part Exam
1) Measure Volume of Salivaproduced with Stimulation<5ml in 5 minutes = dry mouth
2) Test pH
3) Test Buffering Ability
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Reconstructive Phase
1) Direct Restorations2) Indirect Restorations3) Removable Prosthetics4) Implant Supported Prosthetics
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Dual Force - Clinician’s Choice
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Clinician’s Choice Polishing
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⊗ Fails to restore proximal anatomy
⊗ Thin contact at the marginal ridge
⊗ Large food trap below
⊗ Increased likelihood of fracture, occlusal
interference, recurrent caries and periodontal disease.
!Operator-friendly retaining system
! Naturally contoured bands
! Anatomically correct contacts
! Contacts at the height of contour
! Contacts so tight you’ll need a hemostat to get the
band out!
Tofflemire & Standard Wedge
Sectional Matrix Band With Anatomic Wedges
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Maintenance Phase
1) Continuing Care2) Oral Hygiene Instruction and Reinforcement 3) Prosthetic Maintenance
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Develop Your Own Rating System
Patient Disposition Patient Belief OrientationPatient Treatment GoalsLip PositionMaterials PresentSupporting Stability
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Three Biggies
Patient Disposition Patient Belief OrientationPatient Treatment GoalsLip PositionMaterials PresentSupporting StabilityGingival Biotype
32%
42%
26%
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Develop Your Own Rating System1 through 10 ranking
1) Simple (1-2)2) Routine (3-4)3) Average (5-6)4) Complex (7-8)5) Wow! Extremely Challenging (9-10)
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Management of ComplexRestorative Cases
We will look at a number of cases whichdemonstrate many different issues commonly
confronted during treatment planning
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Longevity of Restorations
FPD 3568 211 76 26Implant FPD 3844 560 176 28Implant SC 2560 356 76 26
Pjetursson, Bragger and Lang, Comparison of survival and complication rates of tooth-supported fixed partial dentures (FPDs) and implant-supported FPDs and single crowns (SCs) Clin. Oral Impl. Res, 2007
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Longevity of Restorations
5 Year 10 Year
FPD 93.8% 89.2%Cantilever FPD 91.4% 80.3%Implant FPD 95.2% 86.7%Combined FPD 95.5% 77.8%Implant SC 94.5% 89.4%
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Complications of Restorations 5 Year
FPD 15.7% loss of vitality 6.1% decay of abutment 4.8% loss of retention 3.3% Cantilever FPD 20.6% loss of vitality 7.9% decay of abutment 4.7% loss of retention 3.3%
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Complications of Restorations 5 Year
Implant-supported FPD 38.7% fracture of porcelain 11.9% soft tissue complications 8.6% loss of retention 5.7%
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Longevity of Restorations Vital Non-vital Years3 unit PFD 83% 76% 15All FPD’s 84% 64% 16Cantilever 74% 52% 16
De Backer, Van Maele, Long-term Survival of complete crowns, fixed dental prostheses, and cantilever fixed prostheses with post and cores on root canal-treated teeth Int J Prosthodont 2007; 20:229-234
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Interdisciplinary Management of Anterior Dental EstheticsSpear and friendsDiagnostic and Technical Approach to Esthetic RehabilitationsRomeo and BrecianoThick vs. Thin Gingival Tissue, a Key Determinant in Tissue
Response..Kao and PasquinelliFacing the Challenges of Ceramic VeneersChristensenElective vs. Mandatory DentistryChristensen
Supporting Literature
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Our PatientClinical Condition: Worn dentition, need your help Wife wants teeth fixed!
Treatment Plan: ? Limitations: Funds, no desire to improve
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What Would You Do?
Your Training
Your Experience
The Evidence Continued Expansionof Skills
Patient Desires
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Our Next PatientClinical Condition: Heavily restored, never wants dentures, significant discomfort.
Treatment Plan: ? Desires: Wants to keep teeth!
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Radiographs 1995
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Clinical Findings
1) FDP fabricated 15 years earlier2) Endodontic treatment #313) 10 mm pocket on distal lingual #314) Localized infection and pain #31
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Second Patient - JenniferRadiographs 1995
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Clinical Findings
1) Crowns on lower arch fabricated over the last two decades2) Endodontic treatment #18, 19, 203) 10 mm pocket on mesial buccal #194) Localized infection and pain #19
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What Would You Do?
1) Section FDP #29-31, Extract #19 and RPD2) Section FDP #29-31, Extract #19 and Nothing3) Section FDP #29-31, Extract #19 and Three Implants4) Section FDP #29-31, Extract #19 and Two Implants #30-31 and FDP #18-20Distal Root Amputation #31, New FDP, Implant #195) Something Else
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January 2011
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Selected Treatment - 1995
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Recall Radiographs 2012
17 year recall
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Comparison of Resected Molars and Implants (15 Year Follow Up)
• 23 of 701 resected molars lost (3%)• 44 of 1,472 implants failed (3%)• Highest failures occurred with distal root resections that
created lone-standing (last tooth in the arch) mandibular molars (25%)
• Parafunction increased failure
Fugazzotto, PA. J Periodontol 2001;72:1113-23
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Our Next PatientClinical Condition: Failing FDP #18-20.
Treatment Plan: ? Desires: Doesn’t Want Removable
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FPD 1975-1991
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FPD 1991- 2008
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What Would You Do?
1) Endo #18, Crown Lengthen #18 and New FDP2) Section FDP, Ext. #18 and Implant #193) Section FDP, Ext. #18 and Implant #18 and #194) Section FDP, Ext #18 and No Replacement5) Section FDP, Ext # 18 and RPD6) Endo #18, Distal Root Resection and New FDP7) Something Else
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Next PatientClinical Condition: Multiple Broken Restorations Failing Occlusion, Difficult Referred By Another Dentist Treatment Plan: ?
Rationale: ?
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“Typical” Behavior
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T-scan Occlusal Adjustment
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Next PatientClinical Condition: Wants 20 Year Old Veneers Restored, Referred by Periodontist Treatment Plan: ?
Rationale: ?
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Treatment Options1) Do Nothing - Night guard2) New Veneers on Maxillary Arch3) Full Mouth Reconstruction4) Restore Mandibular Arch and Maxillary Anterior5) Orthodontics and Selected Restorations
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Our Next PatientClinical Condition: FPD From #7-11 Failed 6 Mon. Post Cementation Treatment Plan: Remake FPD #7-11 with Improved Anterior Guidance
Rationale: Patient Wants FPD Monday, March 19, 18
Pre-Op Condition
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What Would You Do?
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Clinical Slides
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Clinical Procedure
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Completed Case
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Before and After
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RecallPatient at 1 year
Patient at 5 year
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Vertical Dimension Changes
Mohindra N. K, Bulman J.S, The Effect of Increasing Vertical Dimension of Occlusion on Facial Aesthetics. British Dental Journal, 192, #3
(February 2002) 164-172
96 patients treated.80% reported to appear between 5-20 years younger.
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Chief Concern: I’ve destroyed my teeth from bulimia and want them fixed.
Monday, March 19, 18
What would you do?
1) Refer her to an orthodontist 2) Refer her to a prosthodontist3) Full mouth reconstruction at current VDO4) Full mouth reconstruction at new VDO5) Other
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Challenging Vertical Dimension Case
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Right Lateral 1:2Full Smile 1:2Left Lateral 1:2
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Occlusal Pre-Operative
Views
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Pre-Operative Condition
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TreatmentOptions?
1) Do nothing2) Reconstruct at current vertical dimension3) Reconstruct at new vertical dimension4) Minimal restorative and splint coverage5) Orthodontics to improve positioning of teeth and vertical dimension6) Esthetic crown lengthening7) Others?
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All Case Designs Must Start With Maxillary Central Incisors
Interdisciplinary Management of Anterior Dental Esthetics
Spear and friends
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Critical Anatomic Features
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Shape and Functional Try-in
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Splint Used At Designed VDO
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AnteriorRestorations
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Maxillary Provisionals Removed
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Tissue Management Issues
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Completed Case
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Vertical Dimension Changes
Mohindra N. K, Bulman J.S, The Effect of Increasing Vertical Dimension of Occlusion on Facial Aesthetics. British Dental Journal, 192, #3
(February 2002) 164-172
96 patients treated.80% reported to appear between 5-20 years younger.
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Completed Case
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Completed Case
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mgeissbergerdds@gmail.com
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